Healthcare Provider Details

I. General information

NPI: 1912274051
Provider Name (Legal Business Name): CREEK ROAD ORTHODONTICS AND PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7410 CREEK RD SUITE #200
SANDY UT
84093-6140
US

IV. Provider business mailing address

7410 CREEK RD SUITE #200
SANDY UT
84093-6140
US

V. Phone/Fax

Practice location:
  • Phone: 801-562-5505
  • Fax:
Mailing address:
  • Phone: 801-562-5505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number76505
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number76505
License Number StateUT

VIII. Authorized Official

Name: DR. BARNEY TODD OLSEN
Title or Position: DENTIST/OWNER
Credential: D.D.S., M.S.
Phone: 801-562-5505